CHAPTER I THE PROBLEM AND ITS SCOPE

Rationale of the Study The spread of Leptospirosis is one the most feared effects of calamities such as floods and the increase on the rate of occurrence of such natural

disasters intensifies the need for people in calamity risk areas to have full awareness, knowledge and responsive health behaviors towards this fatal disease. Leptospirosis is a systemic illness caused by the spirochete Leptospira interrogans and is considered the most common zoonosis worldwide. The disease is essentially spread by animal urine that has contaminated the environment. Clinically it can take many forms, from a mild disease which may be difficult to detect, to an outbreak of fatal cases. Historically, Leptospirosis has been most identified as an occupational disease affecting farmers, veterinarians, abattoir workers, rodent-control workers, and military troops. However, since the 1970s, national trends and local data from Hawaii have shown that most cases are related to recreational exposures. There were reports on two epidemiologically linked cases of Leptospirosis associated with freshwater exposure after a flood on the campus of the University of Hawaii (UH). These cases underscore the importance of maintaining clinical suspicion for Leptospirosis after urban flooding in endemic areas and also highlight an unusual occupational exposure (Geynor et. al. 2007). (http://www.ajtmh.org/content/76/5/882.full.pdf+html)

According to WHO 1999, half a million cases of Leptospirosis are estimated to occur on all continents except Antarctica each year, with most cases being reported in the tropics. Symptoms, which can be difficult to distinguish from other diseases, include fever, aches, chill and more severally, jaundice, acute renal failure and bleeding (Ko, 2009). Animal reservoirs, most commonly rats in urban areas, obtain the disease and fight off the infections in all main organs except for the renal tubules, allowing the Leptospira bacteria to be released in the animals urine (Ko 2009). The disease is then transmitted to humans either through direct contact with the animal, or contact with the animals urine in water or mud. Human contact with the Leptospira bacteria is more likely to occur during periods of flooding in the household and/or streets, or while working in sewers or with trash (Ko 2009). Transmission occurs when the Leptospira bacteria penetrates abraded skin (Ko 2009) thereby putting communities that cannot afford protective gear (i.e. boots, gloves, and pants) at an elevated risk of Leptospirosis, especially during rainy periods. Signs of disease may differ considerably according to the association between the serovar-host, the serovar itself and the exposed host. In humans the clinical signs are usually non specific (flu-like symptoms) and the disease may remain undetected. The second phase of the disease includes meningitis, liver damage (causing jaundice), and renal failure. The infection is often wrongly diagnosed due to the wide range of symptoms. This leads to a lower registered number of cases than exists. Symptoms of Leptospirosis include high fever,

severe headache, chills, muscle aches, and vomiting, and may include jaundice, red eyes, abdominal pain, diarrhea, and rash. Initial presentation may resemble pneumonia. The symptoms in humans appear after a 414 day incubation period. Complications include meningitis, extreme fatigue, hearing loss, respiratory distress, azotemia, and renal interstitial tubular necrosis, which results in renal failure and often liver failure (the severe form of this disease is known as Weil's disease. Cardiovascular problems are also possible (Berger 2006). A vaccine for Leptospirosis is available and used in some countries in Europe and Asia. It must be given every year like a flu shot. A longer-acting vaccine is being investigated in Cuba. It is not currently available in the United States. Travellers who are going to an area where Leptospirosis is common and who will be engaged in activities that increase likelihood of exposure can take 200 mg of doxycycline per week by mouth starting before and during the time period of potential exposure. According to the Leptospirosis Information Center, there are no drug-resistant strains of the bacteria at this time (Cunha et. al. 2000). With the current status of global climate change together with a lot of alterations in the Earths natural balance, there is a higher rate of occurrence of floods and in fact, the trend is still increasing. This alarming truth puts a lot of people in danger especially those who live in flood risk areas. Flood risk is not just the likelihood of flooding, but the possible damage a flood could do as well. This entails moreover that there is also a propensity of Leptospirosis outbreaks to

happen. Most of the people affected by floods have not anticipated the Leptospirosis outbreak to happen increasing their vulnerability and escalating the danger into a higher level. The alarming rate in the increase of flood occurrences implies that there is an equal level of need to prepare not just for the direct damages of the flood but also for the after effects like that of Leptospirosis outbreaks. Just recently, a tropical storm devastated some parts of the Philippines on the seventeenth of December, 2011. The devastation that Tropical Storm Sendong left behind

brought an outbreak of Leptospirosis in the affected cities in Mindanao including Cagayan de Oro and Iligan City (Literatus 2012). This intensifies the need to reevaluate the people residing in flood risk barangays as to whether or not they have awareness and knowledge about the nature of the Leptospirosis disease, how it is acquired, the symptoms and more importantly, the proper health behaviour to best respond to such cases. Although it is a general concession that the public in general should have the aforementioned awareness, knowledge and health behaviour, there is a grave need for context-specific studies in local flood risk barangays to clearly see and evaluate how things really operate on the ground level. Moreover, it has to be noted that the medical are always open to anyones avail. However, this doesnt quite seem to happen because of peoples inadequacy of knowledge and awareness that in turn hinders them from doing appropriate health actions. The inadequacy point to a number of causes, however, predominant amongst all of the causes is the socio-demographic profile

of an individual. Thus, the conduct of this research does not only deal on the determination of knowledge and awareness of people to Leptospirosis but also a validation to some existing studies that unanimously contend that the demographic profile of an individual, to some extent, can predict the individuals behaviour towards health.

Theoretical Background This studys theoretical framework is anchored on the Health Belief Model. Such model will guide in the acquisition of information about the Awareness, Knowledge and Behavior of the respondents regarding Leptospirosis. The model states that the peoples beliefs influence their health- related actions or behaviors. It is a framework used to understand individuals psychological readiness or intention to take a given health action, considering the differences of peoples health beliefs ergo the eventual differences of their health actions

whenever they are faced with health risks such as the disease being considered in this investigation. (Contento, 2010). The basic components of Health Belief model are derived from a wellestablished body of psychological and behavioral theory whose various models hypothesize that behavior depends mainly upon two variables (1) the value placed by an individual on a particular goal (2) and the individuals estimate of whether he could achieve that goal or not. When these variables are conceptualized in the context of health related behavior, the correspondences

where (1) the desire to avoid illness and (2) and a belief that a specific action can prevent or ameliorate a disease (Rockenstock,1974). In theory, peoples likelihood of taking a specific health-related action is generally motivated by five factors perceived severity, perceived susceptibility, perceived benefits, perceived barriers, self efficacy, and cues to action (Becker, 1980) (1) perceived severity or beliefs about the seriousness of contracting an illness or other health-related condition; (2) perceived susceptibility or the belief about the possibility or likelihood of personally contracting the illness or other health-related condition; (3) perceived benefits or opinions of whether a particular action or behavior is useful or effective in reducing the risk or threat of getting the condition; (4) perceived barriers or perceptions of the difficulties of performing the behavior, either physical or psychological; (5) self-efficacy or the confidence to perform the behavior; and (6) cues to action that influence the perceived threat for the condition and increase the likelihood that the individual will take action (Becker, 1980). Leptospirosis is an emerging infectious disease with worldwide

distribution. The disease is endemic in humid, tropical, and subtropical areas of the world where most of the developing countries are located (Brooks, 2004). In Asia Pacific region, Latin America and in Southeast Asia, it is highly prevalent and there has been a marked increase in the number of outbreaks and cases reported during the last two decades (Victoriano, 2009). Even though the disease is mostly endemic in rural settings, an increasing number of cases and frequent outbreaks among urban dwellers is a recent finding worldwide (Gaynor, 2007).

The health behaviors of people towards the contraction of Leptospirosis, just as health belief model would suggest, is dependent on the mentioned dimensions. However, all of those dimensions suggest that people be adequately aware and knowledgeable so that they could take accurate measures whenever the problem would arise. A research conducted in Sri Lanka which experienced the worst ever outbreak of Leptospirosis in 2008 stemmed from the assumption that one major determinant of control and prevention of communicable diseases is public awareness on the disease. The study then determined awareness on Leptospirosis among public Sri Lanka by conducting a national household survey participated by 602 participants. Of them 93.7% were aware of rat as a reservoir animal, but only 3% were aware of the role of cattle and buffalo. Contact with infected water as a mode of transmission was reported by 57.9% of the population. Only 30.8% of the subjects were aware of that the infection can go through skin breeches. Farming as a risk activity was reported by 63.5% of the patients, but knowledge on other exposure activities were less than 20%. Paddy field work and cleaning garbage were correctly identified as risk occupations by 89.7% and 27.6% of the sample, respectively. Respondents were aware of fever (86%), malaise (30.8%), headache (29.6%) and muscle tenderness (28.8%) as main clinical features of the disease. Most of them (73.7%) knew Leptospirosis as a lethal condition and 39.5% were aware of chemoprophylaxis. Conducting assessments on the level of knowledge, awareness, and health behavior of individuals in a community just like the research above is very

essential for medical professional to serve their roles in society. A parallel research conducted by Variyam et al (1996) supports such claim when they investigated on how nutrition knowledge and attitudes vary across different population groups. The researchers of the study believe that data on the health knowledge and awareness of individuals is critical for designing and evaluating nutrition education programs and monitoring the nation's progress toward health goals. The investigation centered on establishing a model that will estimate the relationships between an individuals socio-demographic characteristics and his or her fiber knowledge, attitude and disease-awareness. The results suggest that people of low educational level and income exhibited the least knowledge about the topic. Another research supported the contention on the relatedness of the demographic profile of an individual to his health knowledge, awareness, and behavior. A cross sectional study was conducted among Mexican university students to determine which demographic variables predict the health lifestyle of a person and to estimate the strength of relationship between the identified variables and to the type of lifestyle an individual undertakes. Results of the study revealed that the health behavior of a person is predicted by his gender, socio-economic status, and his mothers education (Diez, 2010). As the WHO puts in its book entitled Health in Asia and the Pacific (2008), economic, social, and environmental factors are strong determinants of health in society. Most of these determining factors are directly linked to a persons inaccessibility to proper education and good quality of life. Addressing these

determinants is as vital as finding a cure to a disease. Acquisition of disease due to inappropriate behavior will always happen unless a cure to these determinants is found. With all of the literatures and related studies provided above, it is made clear that the framework of this research stands strongly on the determination on the association of the demographic profiles of residents living in flood risk areas in Iligan City to their level of knowledge, awareness, and health behavior towards Leptospirosis.

THE PROBLEM

Statement of the Problem This study primarily aims to evaluate the awareness, knowledge and health behavior of the respondents of selected flood risk barangays in Iligan City about Leptospirosis. Specifically, this study aims to answer the following problems: 1. What is the profile of the respondents as to: a. Age b. Gender c. Marital status d. Religion e. Educational attainment f. Occupation 2. What is the status of the respondents as to their awareness on the disease prevalence? 3. What is the level of knowledge among the respondents regarding Leptospirosis? 4. What is the health behavior of the respondents relating to Leptospirosis? 5. Is there a significant relationship between the demographic profiles of the respondents to their awareness on the disease prevalence? 6. Is there a significant relationship between the demographic profiles of the respondents to their level of knowledge regarding Leptospirosis?

7. Is there a significant relationship between the demographic profiles of the respondents to their health behavior regarding Leptospirosis? 8. Is there a significant relationship between the awareness of the disease prevalence of the respondents to their health behavior regarding

Leptospirosis? 9. Is there a significant relationship between the levels of knowledge of the respondents to their health behavior regarding Leptospirosis? 10. Is there a significant difference on the levels of awareness of the respondents in Mahayahay from the respondents in Tambacan? 11. Is there a significant difference on the level of knowledge of the respondents in Mahayahay from the respondents in Tambacan? 12. Is there a significant difference on the health behaviors of the respondents in Mahayahay from the respondents of in Tambacan?

Null Hypotheses The following hypotheses will be tested in determining relationships between the demographic profiles of the respondents and their subsequent knowledge, awareness, and health behavior with regard to Leptospirosis: H01: There is no significant relationship between the respondents profile and their awareness on the disease prevalence. H02: There is no significant relationship between the respondents profile and their level of knowledge regarding Leptospirosis.

H03: There is no significant relationship between the respondents profile and their health behavior regarding Leptospirosis. H04: There is no significant relationship between the respondents awareness on the disease prevalence and their health behavior regarding Leptospirosis. H05: There is no significant relationship between the respondents level of knowledge and their health behavior regarding Leptospirosis. H06: There is no significant difference on the levels of awareness of the respondents in Mahayahay from the respondents in Tambacan. H07: There is no significant difference on the level of knowledge of the respondents in Mahayahay from the respondents in Tambacan. H08: There is no significant difference on the health behaviors of the respondents in Mahayahay from the respondents of in Tambacan.

Significance of the Study Leptospirosis is a zoonotic disease of worldwide distribution. It is believed to affect human beings regardless of origin, ethnicity, gender, economic status, educational attainment and religion. It emerges as an important public health problem especially in developing countries such as ours. It is believed as an important occupational and social hazard especially to people who are most accessible to wet conditions such as frequent flooding. Although the disease is generally endemic in both rural setting, frequent urban outbreaks are being reported s a recent finding worldwide (Bharti AR, Nally JE, Ricaldi JN, Matthias

MA, Diaz MM, Lovett MA, et al. Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis. 2003;3(12):75771.) Knowledge and awareness of this disease amongst people is therefore very necessary ergo the conduct of an assessment of peoples awareness and knowledge about it is important too The results of this investigation shall become a contemporary data that can be used to validate governmental efforts in promoting awareness and knowledge about Leptospirosis. The strength of a governing body is being drawn from the quality of life its people has. A government, no matter its size, shall become weak if it is constantly being threatened by a disease that could go outbreak if no necessary precautions are being taken. Thus, it has been a fact that a number of public seminars has been launched in areas where Leptospirosis can be an imminent danger such as the one chosen by the researcher areas where flooding is a common scene. The figures that will be accumulated about the knowledge, awareness, and health behavior of the respondents shall gauge whether the governments efforts towards health awareness is realized, or it just went otherwise. Other significant aspect of this research points to the fact that it would provide local medical practitioners such as nurses a contemporary empirical data on the adequacy of knowledge and health behaviors of residents living in floodinfested areas. Formulation of management strategies for these residents may have a significant impact on disease progression. The data will enable medical practitioners to devise suggestive measures in order for people to take

appropriate actions towards Leptospirosis and thus cease the apprehended eventual loss of lives from something that could be easily fought. Above anything else, the researchers believe that the residents who could be affected by Leptospirosis are best benefitted from this investigation, since the primordial reason of this research is to assess their knowledge and health behavior in order to devise measures where they could act appropriately whenever infected. Promotion of knowledge alone is not enough to conjure behavioral change, but awareness and knowledge are strong platforms to alter health behaviors of these stakeholders. Acquisition of Leptospirosis could sometimes become inevitable especially in flood risk places, but having to succumb to it is very circumstantial. Most often than not, the reason for Leptospirosis-related deaths is attributed to peoples lack of knowledge and inappropriate actions towards it.

RESEARCH METHODOLOGY

Research Design The research is a cross-sectional survey study which utilizes quasiquantitative approach in determining the level of knowledge, awareness, and health behavior of respondents living in flood-risk areas about Leptospirosis using an expert validated questionnaire. Moreover, the research is also associational in nature as it would seek to determine how the aforementioned factor associates to the demographic profiles of the respondents in general. This being done offshoots to a psychological model that will explain and predict health behaviors of individuals of differing demographic about the concerned disease. The concept framework of the research method is shown in the figure below.

Locale of the Study The study will be conducted in two flood risk barangays of Iligan City, a highly urbanized industrial city north of the province of Lanao del Norte, Philippines, and the province's former capital. It is approximately 795 kilometers southeast of Manila. According to the 2007 census, it has a population of 318,040 people. Iligan City is positioned 8 13 0 north latitude and 124 14 0 east longitude, bounded on the north by the 3 municipalities of Misamis Oriental, to the south by the 3 municipalities of Lanao del Norte and the 2 municipalities of Lanao del Sur, to the northeast by Cagayan de Oro City, to the east by the municipality of Talakag, Bukidnon; and to the west by Iligan Bay.

Iligan falls within the third type of climate wherein the seasons are not very pronounced. Rain is more or less evenly distributed throughout the year. Because of its tropical location the city does not experience cold weather. Neither does it experience strong weather disturbances due to its geographical location being outside the typhoon belt. And also because of the mountains that are surrounding the city. However, on the night of December 16, 2011, the city was hit by Tropical Storm Washi, or locally known as Sendong, which made landfall in Surigao del Sur, travelling inland of Mindanao. In just 10 hours, torrential rainfall led to catastrophic flooding in Iligan and other provinces of Mindanao. Out of the 44 barangays politically subdividing the city, Barangays Mahayahay and Tambacan (See Appendix) are considered flood risk areas where Leptospirosis can be evident. These barangays will be the locale of the investigation. Mahayahay has a total of 2053 households and 10203 residents as of 2007. Of the population, 5133 are female and 5,070 are male. On the other hand, Tambacan holds 2,799 households with a total population of 14, 714 7364 of which are male and 7358 are female (See Appendix for the complete statistic of both barangays). Both barangays recorded cases of Leptospirosis after being struck by Sendong. A number of the people who acquired the disease were reported to have died due to inappropriate health behaviors attributed to the residents insufficient knowledge about the disease.

Respondents of the Research The respondents of the research are 200 residents aging 18 60 years old who currently live in each of the aforementioned flood risk barangays. No demographic standards shall be used in choosing the respondents. Thus, anyone who falls on the age bracket can be a respondent. Convenience sampling will be utilized in the determining who the respondents will be in both barangays due to accessibility constraints. The respondents will receive a consent letter before they will answer the questionnaire that will assess their knowledge, awareness and health behaviors.

Research Instrument Determination and evaluation of the respondents demographic profile and level of knowledge, awareness, and health behavior will be done using self-made questionnaire (see Appendix A). Validation of the questions included in the questionnaire is done only through expert judgments. The questionnaire has four parts each part is specifically intended to assess each of the four factors mentioned earlier. The first part will determine the respondents demographic profile in terms of age, gender, marital status, religion, and educational attainment. The second part will assess if the respondent have heard of any reported case related to Leptospirosis that gave them awareness about the disease. The third part, on the other hand, is a 14-item true-or-false test that will gauge the knowledge of the respondents about Leptospirosis. The respondents on this part of the questionnaire can opt to choose a third option that

tells they do not have any idea on the answer to the question given. Such choice will automatically be considered wrong by the researcher. Moreover, the residents health behavior towards Leptospirosis management is determined in the last part of the questionnaire. This part utilizes a 3-point frequency rating scale that will reveal how often respondents do appropriate or inappropriate health behavior.

Research Procedure Data Gathering. Before gathering the data from the cited locales of the study, the research would have to send a consent letter addressed to the chairpersons of the barangays eliciting their consent on the researchers intent of investigation. Upon approval, the researcher will then go to the chosen sample area and individually check on the households for residents that will qualify on the age criterion set in this research. The researcher will have to present a consent letter coming from the chairperson of the barangays to ensure the legitimacy of the visit. Permission from the qualified respondents shall be asked face to face. The researcher will have to explain the purpose of the visit and guarantee that the any information divulged by the respondent shall be treated with utmost respect and confidentiality. If permitted, the researcher shall then read and explain each of the items in the questionnaire. The respondents will not be allowed to bring the questionnaires with them so as to determine the current level of knowledge and awareness that they have upon the schedule of visitation. The answers to each of the questions will be written by the researcher herself.

The researcher will visit all accessible households until the desired sample size is achieved in both barangays. The data that will be gathered shall then be organized in both graphical and tabular presentations for statistical treatments. Treatment of Data. The data that will be gathered during the household visitations will be treated statistically to be able to answer the problems in this study. All of the analyses will be done using MegaStat, an add-in application to Microsoft Excel. For unpaired non-parametric data with more than two groups, Kruskal-Wallis test will be used, and for parametric unpaired data; Analysis of Variance (ANOVA) will be used. On the other hand, unpaired non-parametric data with two groups, Mann-Whitney test will be used and t-test will be used to analyze data from two unpaired parametric groups. Correlations of

nonparametric and parametric data will be analyzed using Spearman and Pearson tests, respectively. Tests for relationships between variables will be done using Chi-Square.

DEFINITION OF TERMS To facilitate better understanding of the terms used in this study, the following are defined operationally: Age refers to how long the person has lived and obtain capacities to be responsible for his own health and well-being Awareness refers to recognition and familiarity of the number of cases of a Leptospirosis that are present in a particular population at a given time Educational Attainment highest level of education/schooling completed by the respondent Flood Risk Barangays areas in Iligan City that was greatly affected by the recent 2011 flashflood incident Gender Health Behavior refers classification of sex either male or female an action taken by a person to maintain attain or regain good health and to prevent Leptospirosis. Knowledge detailed and in-depth understanding of a person about the cause, mode of transmission, prevention and management of Leptospirosis Marital Status Occupation Religion the condition of being married, unmarried or child a kind of work a person does for a living set of spiritual beliefs, values, and practices

REFERENCES

James, W. D., Berger, T.G., & Elston D.(2006).Andrews' Diseases of the Skin: Clinical Dermatology. Saunders: Elsevier.

Ko A.I., Mitermayer G.R., Ribeiro Durado C.M., Johnson W.D., Riley L.W. (1999).Urban Epidemic of Severe Leptospirosis in Brazil. The Lancet, 354, 820 825.

Rockenstock.(1974).Historical Origins of the Health Belief model. Health Education Monographs 2, 332.

Becker MH,& Maiman LA.(1980). Strategies for enhancing patient compliance. Community Health 6, 113 135

Brooks GF, Butel JS, Morse SA, Brooks G, Butel J, Morse S. 23rd ed. Philadelphia: McGraw-Hill Medical; 2004. Jawetz, Melnick, and Adelbergs Medical Microbiology 33840.

Victoriano AF, Smythe LD, Gloriani-Barzaga N, Cavinta LL, Kasai T, Limpakarnjanarat K, et al. Leptospirosis in the Asia Pacific region. BMC Infect Diseases, 9, 47.

Gaynor K, Katz A.R., Park S.Y., Nakata M., Clark T.A., Effler P.V. (May 2007) Leptospirosis on Oahu: An Outbreak Associated with Flooding of a University Campus. American Journal of Tropical Medicine and Hygiene, 76, 882 886.

APPENDIX A Questionnaire

APPENDIX B Aerial Picture of Mahayahay and Tambacan